Every finding on record at Victory Hospice LLC

Upon patient record review, 1 of 1 (Patient #1) did not have evidence that the IDG shares information on a on-going basis with non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions. Patient #1, No evidence of wound care provided by specialist was documented in IDG meetings. No evidence of coordination of care with wound care specialist.

Upon personnel record review, 1 of 8 (Personnel # 8) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: • Physician services (may contract for physician services) • Nursing • Medical social services • Counseling Personnel #8, Contract signed by nurse practitioner on August 1, 2025. No evidence of W-4 completed, the W-4 in personnel record was blank. In addition, the Wound care specialist was performing wound care that was not highly specialized wound care. Wound care specialist documented wound is not related to terminal diagnosis. No evidence Medical Director had determined if wound care was related to terminal diagnosis.

Upon patient record review, 3 of 14 (Patient # 5, 6, and 7) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient 5: Election of Benefit consent form completed at SOC on 6/2/25 does not include documentation of patient/family choice of attending physician. The checkbox area of patient choice of attending physician or declining choice is left blank and no physician information of preferred choice of attending is evident. Patient 6: Election of Benefit consent form completed at SOC on 5/29/25 does not include documentation of patient/family choice of attending physician. The checkbox area of patient choice of attending physician or declining choice is left blank and no physician information of preferred choice of attending is evident. Patient 7: Election of Benefit consent form completed at SOC on 5/12/25 does not include documentation of patient/family choice of attending physician. The checkbox area of patient choice of attending physician or declining choice is left blank and no physician information of preferred choice of attending is evident.

Upon patient record review and home visits, 6 of 14 (Patient #1, 2, 3, 4, 5 and 9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: Patient 1: Upon home visit, patient reports and group home caregiver confirms patient takes only four medications including Plavix, vitamin D, aspirin and metoprolol. Agency medication medication profile contains orders for mucinex, losartan, hydrochlorothiazide, simvastatin and Ensure patient denies taking for a long time. Corrected on site medication reconciliation and orders obtained to discontinue medications and POC updated. Patient 2: Upon home visit, medication profile contains PRN medications including acetaminophen, milk of magnesia, senna on agency medication list and not on group home medication list. Corrected on site with medication reconciliation and orders obtained to discontinue medications and POC updated. Patient 3: Upon home visit, agency medication profile contains orders for multi vitamin, ascorbic acid, docusate sodium, senna, acetaminophen, and mylanta and caregiver reports medications were discontinued. Corrected on site with medication reconciliation and orders obtained to discontinue medications and POC updated. Patient 4: The medication profile at recertification on 7/23/25 contains orders for metamucil 2 teaspoon dose and Miralax 17 grams dose powder without specific dose and instructions for dilutant for medications. Corrected on site with medication orders obtained. Patient 5: The medication profile 6/2/25 contains an order for Xalatan ophthalmic eye drops with no directions for which eye to administer eye drops. Corrected on site with new order obtained for directions to administer to left eye. Corrected on site with medication orders obtained. Patient 9: The medication profile 6/3/25 contains an order for glycolax powder 1 gm once daily with no dilutant instructions. Corrected on site with medication orders obtained.

Upon patient record review, 1 of 14 (Patient #8) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient 8: Comprehensive assessment completed by SC on 6/12/25 does not indicate an initial Bereavement assessment was completed. SC assessment documents "Dolores denies bereavement.”

Upon patient record review, 2 of 14 (Patient #1,9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 1: The comprehensive assessment documentation on 07/15/25 contains orders for Plavix and ASA noted on recent POC without risk for bleeding noted. Corrected on site with updates to POC to include bleeding risk. Patient 9: The comprehensive assessment documentation contains an order for Clopidogrel with no risk for bleeding noted in POC. Corrected on site medication orders were discontinued due to patient no longer taking meds and POC updated.

Upon patient record review, 6 of 14 (Patient # 1, 2, 3, 4, 5 and 9) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: The updated POC includes medication orders for mucinex, losartan, hydrochlorothiazide, simvastatin, and Ensure that have been discontinued at group home according to patient/caregiver during home visit. Corrected on site with new orders to discontinue medications obtained and POC updated. Patient 2: The POC contains orders that are discontinued in group home medication list including discontinued PRN medications acetaminophen, milk of mag, senna. Corrected on site with medication orders obtained and POC updated. Patient 3: Medications and foley/nephrostomy tubes were removed from patient and care instructions remain present on current POC. Home meds previously discontinued also remain on POC including orders for multi vitamin, ascorbic acid, docusate sodium, senna +, acetaminophen, mylanta. Corrected on site Med orders and POC updates Patient 4: Updated POC at recertification 7/23/25 includes orders for metamucil 2 teaspoon dose and Miralax 17 grams dose powder without specific dose and instructions for dilutant for medications. Corrected on site with medication orders obtained and POC updated. Patient 5: Initial POC Orders 6/2/25 contains an order for Xalatan ophthalmic eye drops with no directions for which eye to administer eye drops. Corrected on site with medication orders obtained and POC updated. Patient 9: The updated IDG POC on 6/3/25 contains an order for glycolax powder 1 gm once daily with no dilutant instructions. Corrected on site with medication orders obtained and POC updated.

Upon personnel record review, 1 of 13 (Personnel # 13) did not have evidence that the hospice routinely provide substantially all core services directly by hospice personnel (The hospice issues a W-2 form for the employee). These services include: Personnel #13 There is no evidence of the hospice providing all core nursing services directly by hospice personnel. The nurse practitioner was providing direct patient care and performing non-certifying visits to patient homes between recertification periods. The personnel was not a W-2 employee.

Upon personnel record review, 1 of 13 (Personnel # 6) did not have clear evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed Personnel # 6: Aide competencies do not show evidence that each individual bathing task was observed by RN separately or completed with a patient or pseudo patient. The form had a line through all tasks instead of each task checked off as completed for each for the sponge, tub, and shower bath.

Upon patient record review, 4 of 14 (Patient #2,3,4,6) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 2: The aide POC 6/10/25 is blank with no tasks available for aide to complete during aide visits. Patient 3: The aide POC 07/15/25 is blank with no tasks available for aide to complete during aide visits. Patient 4: Updated aide POC 7/21/25 still includes aide POC tasks for bathing, toileting and aide visits after documentation of patient request to discontinue aide visits. Corrected on site aide POC was updated to remove aide visits and tasks per patient request. Patient 6: The aide POC 07/15 /25 is blank without tasks available for aide to complete during aide visits.

Upon personnel record review, 1 of 13 (Personnel #12 ) did not have evidence the individual who supervises volunteers is qualified by meeting the hospice's policies and procedures and/or job description criteria and is a designated hospice employee. Personnel 12: There is not evidence in the personnel file that the Volunteer Coordinator is a designated hospice employee.

Upon contract review, the Nurse Practitioner (DD) did not have evidence the agreement to furnish any services under arrangement included that the hospice must retain administrative and financial management, and oversight of staff and services for all arranged services, to ensure the provision of quality care. Arranged care/services are supported by written contract/agreement that requires all care/services are: Contract 4: There is no evidence of a written contract agreement between the Agency and the contracted nurse practitioner. She has provided direct patient care visits to patient homes for non-certifying visits between recertification periods.

Upon patient record review, 3 of 14 (Patient #5,6,7) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient 5: Election of Benefit consent form completed at SOC on 6/2/25 does not include documentation of patient/family choice of attending physician. The checkbox area of patient choice of attending physician or declining choice is left blank and no physician information of preferred choice of attending is evident. Patient 6: Election of Benefit consent form completed at SOC on 5/29/25 does not include documentation of patient/family choice of attending physician. The checkbox area of patient choice of attending physician or declining choice is left blank and no physician information of preferred choice of attending is evident. Patient 7: Election of Benefit consent form completed at SOC on 5/12/25 does not include documentation of patient/family choice of attending physician. The checkbox area of patient choice of attending physician or declining choice is left blank and no physician information of preferred choice of attending is evident.

Based on record review, interview, and agency policy review, the agency failed to ensure that the initial assessment was completed by a Registered Nurse (RN) within 48 hours of a referral for hospice admission for two of 12 patients (Patient (P) P5 and P11) reviewed,. Failure to complete the initial assessment within 48 hours had the potential for new patients not to have physical, psychosocial, or financial needs addressed in a timely manner. --- Findings include: 1. Review of P5's "Face Sheet," provided by the Administrator, revealed P5 was admitted to the agency on 05/03/24. Review of P5's "Referral Date," located in the Electronic Medical Record (EMR) under the "Profile" tab, revealed the date was 05/03/24. Review of P5's "Registered Nurse (RN) – Routine Patient Assessment Report," located in the EMR under the "Care plan" tab and dated 05/03/24, revealed the assessment was incomplete and assessment areas were blank. There was no information related to vital signs, activity of daily living functional needs, hospice aide tasks, or a narrative summary. 2. Review of P11's "Face Sheet," provided by the Administrator, revealed P11 was admitted to the agency on 10/06/23. Review of P11's "Referral Date," located in the EMR under the "Profile" tab, was noted to be 10/06/23. Review of P11's "Registered Nurse (RN) – Initial/Comprehensive Assessment Patient Assessment Report," located in the EMR under the "Care plan" tab, revealed the assessment was not started until 10/09/23. During an interview on 11/20/24 at 3:48 PM, the Administrator confirmed that P5's admission assessment was incomplete. Additionally, the Administrator stated he/she felt that the assessment may not have carried over from the prior EMR that the agency used. The Administrator confirmed that P11 was admitted to the facility on 10/06/23 and the initial RN assessment was not performed until 10/09/23. The Administrator confirmed that all admission assessments should be initiated within 48 hours of the referral and was not sure why the assessment was late. Review of the facility's policy titled, "Initial Assessment/Comprehensive Assessment," dated 2020 included, ". . . The Hospice RN [Registered Nurse] must complete an initial assessment within 48 hours after the election of Hospice care (unless the physician, patient or representative requests that the initial assessment be completed in less than 48 hours) . . ."

Based on record review, interview, and agency policy review, the agency failed to ensure that the initial comprehensive assessment was completed by the interdisciplinary group (IDG) members within five days of a hospice admission for five of 12 patients (Patient (P) P1, P2, P3, P6 and P11) reviewed. Failure to complete the initial comprehensive assessment within five days had the potential for new patients to have physical, psychosocial, spiritual, or financial needs addressed in a timely manner. --- Findings include:1.Record review revealed P1s admission date was 08/22/24; however, the initial chaplain assessment was not completed until 08/30/24 and the social work (SW) assessment was not completed until 09/02/24. 2.Record review revealed P2s admission date was 06/24/24; however, the initial chaplain assessment was not completed until 07/08/24. 3.Record review revealed P3s admission date was 10/12/23; however, the initial SW assessment was not completed until 10/19/23. 4. Record review revealed P6s admission date was 02/07/24; however, the initial SW assessment was not completed until 02/17/24.During an interview on 11/20/24 at 1:00 PM, the Administrator confirmed that the initial SW and chaplain assessments were not completed within five days of the hospice admission for P1, P2, and P3.5. Review of P11's "Face Sheet," provided by the Administrator revealed P11 was admitted to the facility on 10/06/23. Review of P11's "Social Worker – Comprehensive Assessment Patient Assessment Report," located in the EMR under the "Care plan" tab, revealed the assessment was not started until 10/16/23. During an interview on 11/20/24 at 3:48 PM, the Administrator confirmed that Social Worker and Chaplain assessments should be completed within five days of admission. Review of the undated hospice agency policy titled, "Initial Assessment/Comprehensive Assessment" revealed, ". . . The Hospice lDG, in consultation with the patient's attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after patient's election of Hospice care . . ."

Based on record review, review of agency policy, and staff interview, the hospice agency failed to ensure the facility interdisciplinary group (IDG) meetings for 10 patients (Patient (P3, P4, P5, P6, P7, P8, P9, P10, P11, and P12) records reviewed from a total sample of 12 patients included at a minimum the physician, Registered Nurse (RN), social worker (SW) and chaplain in attendance. Failure to include multiple IDG members in the meetings presents a potential inability to accurately evaluate the patients progress in meeting goals of care. This had the potential to affect the three patients (P1, P2, and P3) who were currently receiving hospice services and all future hospice patients/patient family units. P4, P5, P6, P7, P8, P9, P10, P11, and P12 had been discharged from hospice services. --- Findings include: 1. Record review revealed P3 was admitted to the hospice agency on 10/12/23. During review of the IDG meetings, located in the electronic medical record (EMR), it was noted the IDG meetings for 01/16/24 consisted of the RN, on 01/30/24 the RN and chaplain, on 02/13/24 the RN and SW, on 03/26/24 the RN and SW, on 04/09/24 the RN, on 05/07/24 the RN, physician and SW, on 06/04/24 the RN and SW and on 07/16/24 the RN. 2. Record review revealed P4 was admitted to the hospice agency on 06/14/24. During review of the IDG meetings, located in the EMR, it was noted the IDG meetings for 06/18/24 consisted of the RN, and on 07/02/24 consisted of the RN and SW. 3. Record review revealed P6 was admitted to the hospice agency on 02/07/24. During review of the IDG meetings, located in the EMR, it was noted that the IDG meeting for 03/01/24 consisted of the Medical Director and RN. 4. Review of P5's "Face Sheet," provided by the Administrator, revealed P5 was admitted to the agency on 05/03/24. P5 was discharged on 11/08/24. Review of P5's "IDG Plan of Care & Review of Comprehensive Assessment," with the following dates and located in the EMR under the "Documents" tab, did not include all the necessary attendees at the IDG meetings: 05/07/24 did not include a Social Worker (SW) or chaplain signature, 05/21/24 did not include a SW or chaplain signature, 06/04/24 did not include a chaplain signature, 06/18/24 did not include a SW or chaplain signature, 07/02/24 did not include a chaplain signature, 07/16/24 did not include a SW or chaplain signature, and 07/30/24 did not include a chaplain signature. 5. Review of P7's "Face Sheet," provided by the Administrator, revealed P7 was admitted to the agency on 11/20/23. P7 discharged on 09/07/24. Review of P7's "IDG Plan of Care & Review of Comprehensive Assessment," with the following dates and located in the EMR under the "Documents" tab, did not include all the necessary attendees at the IDG meetings: 11/21/23 did not include a SW or chaplain signature, 12/19/23 did not include a SW or chaplain signature, 01/02/24 did not include a SW or chaplain signature, 01/16/24 did not include a SW or chaplain signature, 01/30/24 did not include a SW signature, 02/13/24 did not include a chaplain signature, 02/27/24 did not include a SW or chaplain signature, 03/12/24 did not include a chaplain signature, 03/26/24 did not include a chaplain signature, 04/09/24 did not include a SW or chaplain signature, 04/23/24 did not include a chaplain signature, 05/07/24 did not include a chaplain signature, 05/21/24 did not include a SW or chaplain signature, 06/04/24 did not include a chaplain signature, 06/18/24 did not include a SW or chaplain signature, 07/02/4 did not include a chaplain signature, 07/16/24 did not include a SW or chaplain signature, and07/30/24 did not include a chaplain signature. 6. Review of P8's "Face Sheet," provided by the Administrator, revealed P8 was admitted to the agency on 11/10/23. P8 was discharged on 10/28/24. Review of P8's "IDG Plan of Care & Review of Comprehensive Assessment" with the following dates and located in the EMR under the "Documents" tab did not include all the necessary attendees at the IDG meetings:11/21/23 did not include a SW or chaplain signature, 12/19/23 did not include a SW or chaplain signature, 01/02/24 did not include a SW or chaplain signature, 01/16/24 did not include a SW or chaplain signature, 01/30/24 did not include a SW signature, 02/13/24 did not include a chaplain signature, 02/27/24 did not include a SW or chaplain signature, 03/12/24 did not include a chaplain signature, 03/26/24 did not include a chaplain signature, 04/09/24 did not include a SW or chaplain signature, 04/23/24 did not include a chaplain signature, 05/07/24 did not include a chaplain signature,05/21/24 did not include a SW or chaplain signature, 06/04/24 did not include a chaplain signature, 06/18/24 did not include a SW or chaplain signature, 07/02/24 did not include a chaplain signature, 07/16/24 did not include a SW or chaplain signature, and 07/30/24 did not include a chaplain signature. 7. Review of P9's "Face Sheet," provided by the Administrator, revealed P9 was admitted to the agency on 10/17/23. P9 was discharged on 01/17/24. Review of P9's "IDG Plan of Care & Review of Comprehensive Assessment," with the following dates and located in the EMR under the "Documents" tab, did not include all the necessary attendees at the IDG meetings: 10/24/23 did not include a SW or chaplain signature,11/07/23 did not include a chaplain signature,11/21/23 did not include a SW or chaplain signature, 12/19/23 did not include a SW or chaplain signature, 01/02/24 did not include a SW or chaplain signature, and01/16/24 did not include a SW or chaplain signature. 8. Review of P10's "Face Sheet," provided by the Administrator, revealed P10 was admitted to the agency on 10/12/23. P10 passed away on 08/22/24. Review of P10's "IDG Plan of Care & Review of Comprehensive Assessment," with the following dates and located in the EMR under the "Documents" tab, did not include all the necessary attendees at the IDG meetings: 10/24/23 did not include a SW or chaplain signature,11/07/23 did not include a chaplain signature, 11/21/23 did not include a SW or chaplain signature, 12/19/23 did not include a SW or chaplain signature, 01/02/24 did not include a SW or chaplain signature,01/16/24 did not include a SW or chaplain signature, 01/30/24 did not include a SW signature,02/13/24 did not include a chaplain signature, 02/27/24 did not include a SW or chaplain signature, 03/12/24 did not include a chaplain signature, 03/26/24 did not include a chaplain signature, 04/09/24 did not include a SW or chaplain signature, 04/23/24 did not include a chaplain signature, 05/07/24 did not include a chaplain signature,05/21/24 did not include a SW or chaplain signature, 06/04/24 did not include a chaplain signature, 06/18/24 did not include a SW or chaplain signature,07/02/24 did not include a chaplain signature, 07/16/24 did not include a SW or chaplain signature, and 07/30/24 did not include a chaplain signature. 9. Review of P11's "Face Sheet," provided by the Administrator, revealed P11 was admitted to the agency on 10/06/23. P11 passed away on 11/08/23. Review of P10's "IDG Plan of Care & Review of Comprehensive Assessment," with the following dates and located in the EMR under the "Documents" tab, did not include all the necessary attendees at the IDG meetings: 10/24/23 did not include a SW or chaplain signature, and11/07/23 did not include a chaplain signature. 10. Review of P12's "Face Sheet," provided by the Administrator, revealed P12 was admitted to the agency on 09/15/23. P12 was discharged on 10/18/24. Review of P12's "IDG Plan of Care & Review of Comprehensive Assessment," with the following dates and located in the EMR under the "Documents" tab, did not include all the necessary attendees at the IDG meetings:10/24/23 did not include a SW or chaplain signature,11/07/23 did not include a chaplain signature, 11/21/23 did not include a SW or chaplain signature,12/19/23 did not include a SW or chaplain signature, 01/02/24 did not include a SW or chaplain signature,01/16/24 did not include a SW or chaplain signature, 01/30/24 did not include a SW signature,02/13/24 did not include a chaplain signature, 02/27/24 did not include a SW or chaplain signature, 03/12/24 did not include a chaplain signature, 03/26/24 did not include a chaplain signature, 04/09/24 did not include a SW or chaplain signature, 04/23/24 did not include a chaplain signature, 05/07/24 did not include a chaplain signature,05/21/24 did not include a SW or chaplain signature, 06/04/24 did not include a chaplain signature, 06/18/24 did not include a SW or chaplain signature,07/02/24 did not include a chaplain signature, and07/16/24 did not include a SW or chaplain signature. During an interview on 11/20/24 at 3:48 PM, the Administrator confirmed that the IDG meetings were to include a RN, chaplain, social worker, and physician. The Administrator stated she felt that the previous EMR did not carry over the signatures to confirm the presence of all required staff. The Administrator confirmed that signatures were missing and should have been obtained for verification of required staff. The Administrator provided handwritten signature sheets, which further confirmed that not all disciplines attended the meetings. Review of the undated hospice agency policy titled "Interdisciplinary Group Meeting," revealed, ";...Hospice has designated an interdisciplinary group which, in consultation with the patient'sattending physician, prepares a written plan of care for each patient. The group consists of: A physician member who is the Hospice Medical Director or another Hospicephysician who is employed by or under contract with Hospice (the physician must be aDoctor of Medicine or osteopathy), Registered nurse, social worker, Pastoral or other counselor..." and ";...The IDG (in collaboration with the patient's attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days..."

Based on interview, record review, and agency policy review, the hospice agency failed to ensure that an individualized plan of care (POC) was developed for four patients (Patient (P) 8, P9, P10, and P11) reviewed from a total sample of 12 patients. Specifically, the facility failed to ensure that a chaplain POC was developed for P8 and P10 and a social services POC was developed for P9 and P11. This had the potential to affect the planning of appropriate/anticipated care needs for the three patients who were receiving hospice services. --- Findings include: 1. Review of P8's "Face Sheet," provided by the Administrator, revealed P8 was admitted to the agency on 11/10/23. P8 was discharged on 10/18/24. Review of R8's "Comprehensive Plan of Care (POC)," located in the Electronic Medical Record (EMR) under the "Downloads" tab and initiated 11/10/23, included spiritual advisor visits once monthly 11/10/23-02/10/24, 05/07/24-06/08/24, and 07/06/24-09/07/24. The POC did not include what spiritual advisor services were to be provided. Review of P8's "Spiritual Care- Initial/Comprehensive Assessment Patient Assessment Report," located in the EMR under the "Care plan" tab and dated 06/18/24, indicated that the patient was to be seen once monthly. Review of R8's "Spiritual Care- Routine Patient Assessment Report," located in the EMR under the "Care plan" tab and dated 07/08/24, indicated that the patient was to be seen once monthly. Review of R8's "Spiritual Care- Routine Patient Assessment Report," located in the EMR under the "Care plan" tab and dated 08/06/24, indicated that the patient was to be seen once monthly. 2. Review of P9's "Face Sheet," provided by the Administrator, revealed P9 was admitted to the agency on 10/17/23. P9 was discharged on 01/17/24. Review of R9's "Comprehensive Plan of Care," located in the EMR under the "Downloads" tab and initiated 10/17/23, included social worker visits once monthly 10/17/23-01/17/24 and 01/15/24-04/16/24. The POC did not include what social services were to be provided. Review of P9's "Social Worker- Comprehensive Assessment Patient Assessment Report," located in the EMR under the "Care plan" tab and dated 10/19/23, did not specify visit frequency. Review of R9's "Social Worker – Comprehensive Assessment Patient Assessment Report," located in the EMR under the "Care plan" tab and dated 11/22/23, did not specify visit frequency. 3. Review of P10's "Face Sheet," provided by the Administrator, revealed P10 was admitted to the agency on 10/12/23. P10 passed away on 08/22/24. Review of R10's "Comprehensive Plan of Care," located in the EMR under the "Downloads" tab and initiated 10/12/23, included spiritual advisor visits once monthly 10/11/23-01/11/24, 04/08/24-05/09/24, 06/07/24-08/08/24, and 08/06/24-10/07/24. The POC did not include what spiritual advisor services were to be provided. Review of P10's "Spiritual Care- Comprehensive Assessment Patient Assessment Report," located in the EMR under the "Care plan" tab and dated 10/17/23, indicated that the patient declined services at that time. Review of P10's "Spiritual Care- Initial/Comprehensive Assessment Patient Assessment Report," located in the EMR under the "Care plan" tab and dated 06/18/24, indicated that the patient was to be seen once monthly. Review of R10's "Spiritual Care- Routine Patient Assessment Report," located in the EMR under the "Care plan" tab and dated 07/08/24, indicated that the patient was to be seen once monthly. Review of R10's "Spiritual Care- Routine Patient Assessment Report," located in the EMR under the "Care, plan" tab and dated 08/06/24 indicated that the patient was to be seen once monthly. 4. Review of P11's "Face Sheet," provided by the Administrator, revealed P11 was admitted to the agency on 10/06/23. P11 passed away on 11/08/23. Review of P11's "Comprehensive Plan of Care," located in the EMR under the "Downloads" tab and initiated 10/09/23, included social worker visits once monthly 10/09/23-01/09/24. The POC did not include what social services were to be provided. Review of P11's "Social Worker- Comprehensive Assessment Patient Assessment Report," located in the EMR under the "Care plan" tab and dated 10/16/23, did not specify visit frequency. During an interview on 11/19/24 at 1:20 PM, the Chaplain confirmed that the initial plan of care was established with the patient, caregiver/family, and the IDG and that initial assessments and initial plans of care were to be completed within five days of admission and with every IDG meeting as needed. During an interview on 11/19/24 at 4:00 PM, the Social Worker (SW) confirmed that the initial plan of care was established with the patient, caregiver/family, and the IDG and that initial assessments and initial plans of care were to be completed within five days of admission and with every IDG meeting as needed. During an interview on 11/20/24 at 3:48 PM, the Administrator confirmed that it was his/her expectation that each discipline initiate and revise care plans upon initial assessment and then every 15 days or as needed as their condition or needs change. The Administrator stated he/she was not aware that the chaplain and Social Services care plans were not completed for these patients. Review of the agency's policy titled, "IDG [Interdisciplinary Group] Care Planning Process" dated 2020, revealed, ". . . All care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient or representative and the primary caregiver in accordance with the patient's needs . . . An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive [sic] and updated comprehensive assessments. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions, including . . . psychosocial, emotional and spiritual needs and reassessing the effectiveness of the current plan of care in order to address those needs . . . The IDG (in collaboration with the patient's attending physician, if any) reviews, revises and documents the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. The revised plan of care includes information from the patient's updated comprehensive assessment and notes the patient's progress toward outcomes and goals specified in the plan of care . . ." Review of the agency's policy titled, "Job Description Social Worker/Social Work Assistant," dated 08/2020, revealed, ". . . Hospice must employ or contract with at least one MSW [Master Social Worker] to serve in the supervisor role as an active advisor . . . developing and updating the social work portion of the plan of care . . ." Review of the agency's policy titled, "Spiritual Services," dated 08/2020, revealed, ". . . Collaborating with other IDG members in the development of the plan of care . . ."

Based on interview, observations, record review, agency policy review, and interview, the hospice agency failed to ensure that patient records were documented and uploaded to the electronic medical record (EMR) in a timely manner for five patients (Patient (P) 5, P8, P9, P10, and P11) of 12 patients. This had the potential to affect the care provided to the patients as well as developing an appropriate plan of care. --- Findings include: Review of the facility policy titled "Timely Submission of Patient Documentation" dated 2020 stated "Itineraries, with all visit reports attached, must be submitted the next scheduled workday [sic], not exceeding three (3) business days..." 1. Review of P5's "Face Sheet" provided by the Administrator revealed P5 was admitted to the agency on 05/03/24. P5 was discharged on 11/08/24. Review of P5's "Registered Nurse (RN) – Routine Patient Assessment" document located in the Electronic Medical Record (EMR) under the "Assessments" tab and dated 05/03/24 was not uploaded until 06/04/24. Review of P5's "Registered Nurse (RN) – Routine Patient Assessment" document located in the EMR under the "Assessments" tab and dated 05/10/24 was not uploaded until 06/17/24. Review of P5's "Registered Nurse (RN) – Routine Patient Assessment" document located in the EMR under the "Assessments" tab and dated 05/23/24 was not uploaded until 06/17/24. Review of P5's "Registered Nurse (RN) – Routine Patient Assessment" document located in the EMR under the "Assessments" tab and dated 06/17/24 was not uploaded until 06/30/24. Review of P5's "Registered Nurse (RN) – Routine Patient Assessment" document located in the EMR under the "Assessments" tab and dated 07/21/24 was not uploaded until 08/04/24. Review of P5's "Registered Nurse (RN) – Routine Patient Assessment" document located in the EMR under the "Assessments" tab and dated 11/03/24 was not uploaded until 11/10/24. Review of P5's undated "Plan of Care Activity" located in the EMR under the "Care plan" tab did not include documentation of chaplain services provided. 2. Review of P8's "Face Sheet," provided by the Administrator, revealed P8 was admitted to the agency on 11/10/23. P8 was discharged on 10/28/24. Review of P8's "Spiritual Care- Initial/Comprehensive Assessment Patient Assessment Report" document, located in the EMR under the "Assessments" tab and dated 06/18/24, was not uploaded until 06/24/24. 3. Review of P9's "Face Sheet," provided by the Administrator, revealed P9 was admitted to the agency on 10/17/23. P9 was discharged on 01/17/24. Review of P9's undated "Plan of Care Activity," located in the EMR under the "Care plan" tab did not include documentation of social services provided. 4. Review of P10's "Face Sheet," provided by the Administrator, revealed P10 was admitted to the agency on 10/12/23. P10 passed away on 08/22/24. Review of P10's "Spiritual Care- Initial/Comprehensive Assessment Patient Assessment Report" document located in the EMR under the "Assessments" tab and dated 06/18/24, was not uploaded until 06/24/24. Review of P10's undated "Plan of Care Activity" located in the EMR under the "Care plan" tab, did not include documentation of chaplain services provided. 5. Review of P11's "Face Sheet," provided by the Administrator, revealed P11 was admitted to the agency on 10/06/23. P11 passed away on 11/08/23. Review of P11's undated "Plan of Care Activity," located in the EMR under the "Care plan" tab, did not include documentation of social services provided. During an interview on 11/20/24 at 3:48 PM, the Administrator stated it appeared that staff were starting documentation of their visits on the date located on the forms; however, the documentation was not completed until the date it was uploaded into the EMR system. The Administrator confirmed it was the policy of the agency to complete documentation within three days.